How many times have you heard, “Only 6% of uterine ruptures are catastrophic?” Or “Uterine rupture not only happens less than one percent of the time, but the vast majority of ruptures are non-catastrophic?”
But what does that actually mean? Does that mean only 6% of uterine ruptures are “complete” ruptures? Result in maternal death? Fetal/infant death? Serious injury to parent or baby?
This article will explain to you the difference between uterine rupture and uterine dehiscence, define catastrophic uterine rupture, as well as explain the source and meaning of that seemingly slippery 6% statistic.
Distinguishing between uterine rupture and uterine dehiscence
First, it’s important to understand what a uterine rupture is and how that differs from a uterine dehiscence. Uterine rupture fundamentally is a full-thickness opening through the uterine wall. During pregnancy, this involves two layers of the uterus, the myometrium (the uterine muscle) and the serosa (the outer uterine layer).
Sometimes uterine rupture can be referred to as a true or complete uterine rupture. I avoid that language because I find it muddies the waters and confuses birthing people. Either the uterine wall separates completely or it does not. If it does, it’s a uterine rupture.
Contrast that with a uterine dehiscence which is not a full-thickness separation. It’s often asymptomatic, does not pose any risk to the birthing parent or baby, and does not require surgical repair.
It is believed that many dehiscences go undiagnosed as the only time they are identified is via an ultrasound, cesarean, or manual uterine exploration after vaginal delivery which is not recommended per ACOG guidelines.
Uterine dehiscence also goes by other names, such as an incomplete uterine rupture or uterine window, which I also avoid in order to reduce confusion particularly among birthing families.
How medical studies define uterine rupture
There is a lot of discussion about how medical studies define uterine rupture. The definition that they use ultimately impacts the uterine rupture rate that they report. If a study defines uterine rupture as any uterine “defect,” it is going to include dehiscence within that definition which inflates the reported uterine rupture rate. If the study only counts a uterine rupture if it's accompanied by some other complication, for example blood transfusion or ICU admission, that is going to result in an underreporting of the event.
I also make note of how uterine rupture data is obtained. It's typically collected from ICD-10 codes or medical records. Medical records are great because it's often clear from the language if it was a rupture or dehiscence. ICD-10 codes carry a shortcoming: they only offer codes for uterine rupture that occurs before (O71.0) and after labor (O71.1), but not uterine dehiscence. So how are dehiscences coded? Are they grouped with uterine rupture? Not coded at all? Based on how research conflates the two events, I wonder if that happens with the coding as well.
We can learn from Denmark's ICD-10 uterine rupture codes
I believe we could all learn from the wonderful work happening in Denmark. I ran across the additional uterine rupture diagnosis codes they created when developing our continuing education training on vaginal birth after classical cesarean. I reached out to the Danish Health Data Agency to learn more. (F. Søgaard, personal communication, March 7, 2024) Here's what they said: in an effort to more accurately measure the incidence of uterine rupture they created additional ICD-10 codes in 2005 for uterine dehiscence (which they call a partial uterine rupture) and complete uterine rupture during birth (DO711AA and DO711AB).
Then in 2010, they added another code for suspected uterine rupture (DO7584). This is brilliant because there are times that an emergency cesarean is performed due to a suspected uterine rupture, but then they get in there and there is no rupture. In fact, per the DHDA, "Suspected uterine rupture is relatively often reported (compared to a true diagnosis of a partial/complete rupture), about 4-5 times as frequent." This is why this code is needed, badly, so we can properly code why an emergency cesarean happened and so studies which pull from this data can accurately measure various events.
Then in 2014, they added two additional codes to measure uterine dehiscence and uterine ruptures that occur before birth. (DO710A and DO710B). As of my March 2024 communication with them, "These ICD-10 codes are all valid and relevant to this day."
If I could wave a magic wand, I would do many things, but one of them would be to add these additional codes to the ICD code catalog, which is owned and published by the World Health Organization, so all who use these codes would have access to this level of reporting. Imagine how that could impact the quality of uterine rupture research available to us?
To be clear, all the studies that we reference here at VBAC Facts® define uterine rupture as a full thickness separation of the uterine wall which distinguishes uterine rupture from uterine dehiscence. And if they don't, but there is some compelling reason to include their study in our work here, we disclose that information while discussing the study so you have full understanding of the topic at hand.
One final note: studies published around the 1980s or earlier typically classify uterine dehiscences as uterine ruptures whereas modern studies typically do not. Nevertheless, one must always perform proper due diligence by reading the methodology section, which we do.
What does the 6% catastrophic uterine rupture statistic mean?
The statistic “Only 6% of uterine ruptures are catastrophic” is from the Guise (2010) Evidence Report which was the basis of the 2010 National Institutes of Health VBAC Conference. Here is the exact quote:
The overall risk of perinatal death due to uterine rupture was 6.2 percent. The two studies of women delivering at term that reported perinatal death rates report that 0 to 2.8 percent of all uterine ruptures resulted in a perinatal death.
In other words, of the birthing people who had uterine ruptures, 6.2% (1 in 16) resulted in perinatal deaths meaning the baby died either during labor or within 28 days of being born. When we limited the data to people delivering at term, as opposed to all gestational ages, the risk decreased to 0 – 2.8% (1 in 36).
These statistics are based on hospital data
One of the key things to keep in mind as we move through this data together: These statistics are based on hospital data, very likely hospitals that have 24/7 anesthesia. So these are uterine ruptures that have access to physicians capable of performing surgery, emergency rooms, blood products, etc and as a result, I would not apply these statistics to uterine ruptures that occur outside the hospital.
There are many factors that impact uterine rupture outcomes, but one of the major considerations is time. Time from symptom to suspected diagnosis (suspected because the uterine rupture is typically confirmed during a cesarean). Time from suspected diagnosis to operating room. Time from incision to delivery. And during this time, the fetus may be deprived of oxygen.
I say may because, again, there are many things that impact uterine rupture outcomes and not all fetuses who experience a uterine rupture will experience oxygen deprivation, and, again, you won't know who does and who doesn't until delivery.
It reminds me of an OBGYN who shared with me that during an elective repeat cesarean section, upon visualizing the uterus, she noted a six centimeter uterine rupture. Not a uterine dehiscence, a full thickness uterine rupture. She was stunned. There was no bleeding. Fetal heart tones were normal. There were no signs or symptoms that this uterine rupture had occurred. This was an elective repeat cesarean section without medical indication. Baby was born healthy, but the OB was quite shocked to say the least.
I share this not to minimize the severity of uterine rupture, but to illustrate the wide range of outcomes that are possible. This is why I don't use language like "all" to describe really anything about VBAC in general and specifically uterine rupture. There are very few scenarios were words like "all" or "none" are appropriate and this is just one example.
The importance of time and community VBAC considerations
But back to time... there are many elements that can impact the time that elapses from initial signs and symptoms to delivery. Being at home or a birth center could add considerable time. Being in the hospital does not guarantee a more rapid diagnosis and response. Sometimes uterine ruptures can occur quickly and without warning, other times there can be numerous "pink flags" well before the rupture occurs which can be used in a home or birth center scenario to transfer with adequate time. Sometimes emergency home/birth center transfers are complicated by the patient and midwife being chastised by hospital personnel rather than addressing the emergency at hand.
Given the lack of data available on out of hospital VBAC, we don't have solid data upon which to compare the two settings. Additionally, there are uterine rupture scenarios that no matter how swift the response, the outcome is dire.
One thing we know for sure: If we want to improve outcomes for obstetrical emergencies, having established protocols in place is an important part of that equation. The California Maternal Quality Care Collaborative has done amazing work in this arena. (Do check out their downloadable toolkits.)
In regards to community birth (home and birth center birth), we can improve outcomes by adopting some of those same CMQCC toolkits as well as integrating community midwives into the larger hospital system. (Step Up Together is one such program that focuses on this work.)
My larger point? There is an opportunity here to improve outcomes and that includes intentional action like working together as a team, creating standardized protocols, and performing regular fire drills. Obstetrical complications are inevitable whether they are during a planned VBAC, a repeat cesarean, or a vaginal or cesarean birth with a first time parent. Training improves outcomes in all settings and scenarios.
At the end of the day, like all matters in health care, it comes down to the laboring person and her care team. Trust. Communication. Symptoms. Readiness. Response. It comes down to the fact that her uterine rupture odds will either be 100% or 0%. She will either rupture or not. Because that is the reality of the situation. If she does, the outcome may be serious or not.
We lean into these statistics - as imperfect as they are - to help us make informed decisions. To give us an idea of how often various outcomes occur so one can weigh the options before them. To consider the risks and benefits to mother now, baby now, mother long term, baby long term, future fertility, future pregnancies, and future babies.
These statistics are based on older data (and a peek at newer data)
The other thing I want to point out before we continue: The data we will discuss from the 2010 Guise evidence review (which ACOG still cites as of their 2019 VBAC guidelines) represents a different time in health care. I say this because O'Neill (2017) examined VBAC outcomes from 1982 - 2010 and noticed:
Although an increased risk of neonatal death was found in women with a TOLAC, there was evidence of a cohort effect, which showed this increased odds disappearing over time. Advances in modern healthcare including improved monitoring and earlier detection of underlying pregnancy complications may explain the findings.
As 2010 was quite some time ago, we might have experienced further improvements. Just one example that illustrates this, in 2018, Vandenberghe examined the outcomes among 627 verified uterine ruptures that occurred during a planned VBAC across nine European countries.
I want to emphasize that word "verified." In this case it means they went into each medical record and confirmed that a complete uterine rupture - not a uterine dehiscence - occurred. This study did not rely on diagnosis codes where sometimes uterine dehiscences can be coded as ruptures and muck up the studies that rely on those codes.
As mentioned before, this distinction between dehiscence and rupture is a critical step when evaluating uterine rupture outcomes, especially uterine rupture related perinatal mortality, where miscoded events can result in inaccurate reporting.
In reading through the full text, it's also important to note how they defined perinatal mortality: fetal deaths after 24 weeks of pregnancy through infant deaths within 7 days of birth. This is another pivotal definition to nail down while reading studies on mortality rates because I have seen other studies and sources define perinatal mortality as stillbirths after 20 weeks through infant deaths within 28 days after birth. So, depending on how big of a net we cast, we are going to get very different numbers. This is one of the reasons why it can be difficult, and at the very least unhelpful, to discuss study outcomes without considering the parameters they use to define the outcomes they study.
Another factor: Uterine rupture may have been under- and over-reported as a result of how each country defined uterine rupture:
The Netherlands used a clinical definition rather than an anatomical definition, namely cases of uterine rupture where clinical symptoms led to an emergency CS or laparotomy; we agreed to include all registered cases, aware that some may have been incomplete ruptures. France registered cases of complete uterine rupture only if associated with severe acute maternal morbidity.
So, there may have been uterine dehiscences included from the Netherlands, resulting in an overreporting, meanwhile, not all uterine ruptures may have been reported from France, just those that resulted in serious maternal complications, resulting in an underreporting.
Are you getting a sense of how tricky this data can be? How easy it can be for an unethical someone with a specific agenda to highlight a distinct slice from a certain angle to illustrate whatever they want? I hope so.
Discussing everything we have in this effective preamble applies attention to the caveats and nuance that is essential to truly understanding what the data says while we get a sense of were the risk lies. It is this level of comprehension that one must master if you want to honestly and effectively communicate the risk of uterine rupture perinatal mortality to others.
One final caveat: location of the study. While European health care differs from the US in some fundamental ways, let's see what is possible from their data. What did Vandenberghe uncover?
The risk of catastrophic uterine rupture is "extremely low"
Vandenberghe reported a uterine rupture perinatal mortality rate during a planned VBAC of 0.032% (3.2 per 10,000 planned VBAC, same as 1 in 3125 planned VBAC) and described this risk as "extremely low."
Notable is the range of uterine rupture rates reported by participating countries: 0.012 - 0.041% (1.2 - 4.1 per 10,000 planned VBAC) (remember how different countries defined uterine rupture?) and the range within the literature: 0.011 - 0.047% (1.1 - 4.7 per 10,000 planned VBAC.)
Nevertheless, as we often express within these discussions, it doesn’t matter how low the risk is when it happens to you. That small number represents the pain and loss of grieving parents. So while it’s important to clarify the low risk, we also have to acknowledge the human loss it represents.
But let's look at the data a different way. In the setting of uterine rupture, what is the risk of perinatal death? It was 9%. 9% might sound low to you, it might sound high. This is why I like to communicate statistics as a ratio because for some that makes the number more understandable/ relatable. In this case, that 9% is the same as 1 in 11 uterine ruptures. In other words, this study found for every eleven uterine ruptures, one baby died.
Notice that 9% feels very different than 0.032%. That's because that 0.032% number is based on all the people who labored, had a uterine rupture, and their baby died. This is an important number when someone planning a vaginal birth after one low transverse cesarean asks, "What are the odds my baby will die if I labor after one prior low transverse cesarean?"
But that 9% statistic looks simply at: If the woman laboring has a uterine rupture, what then? What are the odds that her baby dies? "What are the odds my baby will die if I have a uterine rupture" is an entirely different question.
Do you see how depending how we frame this question, we can either get really big, or really small, numbers? I think both numbers are important during informed consent. Because we need to have a way to talk about the big picture: overall risk of perinatal mortality during a planned VBAC AND the risk if a uterine rupture occurs.
Again, those outcomes are based on factors like
- the size of the uterine rupture
- is the rupture actively bleeding?
- uterine rupture location relative to the placenta
- has her water broken?
- has the fetus moved into the abdominal cavity?
- time to diagnosis
- time to delivery
As you can tell, there is a lot to discuss here. And I want to focus primarily on what ACOG says in their VBAC guidelines and the sources they cite, like Guise (2010), because those are the numbers that most cite. So let's do that.
(While it's outside the scope of this article, I do think it's important to say out loud that fetal oxygen deprivation resulting in brain damage is another serious complication from uterine rupture. Briefly, I want to share that Guise (2010) reports there was low evidence strength on this topic because of all the ways various studies defined brain damage. You will see the number they generated in ACOG's VBAC guidelines below.)
The quality of evidence available on uterine rupture related perinatal mortality is not strong
Guise noted, “Overall, the strength of evidence on perinatal mortality was low to moderate” due to the wide range of perinatal mortality rates reported by the studies included in the report.
In other words, the studies measuring uterine rupture related perinatal mortalities through 2010 observed such divergent numbers that a “middle ground” or “average” number was hard to accurately generate.
I also appreciate their candor when they discuss what we know, what we don’t, and the best guesses we can make based on the available evidence:
Often, however, the data do not allow a direct estimate to calculate the numbers that people desire such as the number of cesareans needed to avoid one uterine rupture related [perinatal] death. The assumptions that are required to make such estimates from the available data introduce additional uncertainty that cannot be quantified. If we make a simplistic assumption that 6 percent of all uterine ruptures result in perinatal death (as found from the summary estimate), the range of estimated numbers of cesareans needed to be performed to prevent one uterine rupture related perinatal death would be 2,400 from the largest study, (204) and 3,900-6,100 from the other three studies of uterine rupture for TOL and ERCD. (10, 97, 205)
ACOG’s VBAC guidelines on planned VBAC and neonatal morbidity
Let's turn our focus to ACOG’s VBAC guidelines. While they don’t address uterine rupture related perinatal mortality specifically, likely because evidence strength is low, they do compare neonatal morbidity rates (complications like brain damage/HIE) during planned VBAC versus elective repeat cesarean section:
I want to highlight a couple things on this chart.
First, for most of these numbers, the risk is higher with a planned VBAC (which they refer to as TOLAC or trial of labor after cesarean), but the absolute risk – the likelihood of these events occurring – is still quite low during a planned VBAC or elective repeat cesarean delivery.
Let’s start with perinatal mortality, which captures fetal deaths after 20 weeks of pregnancy through infant deaths within 28 days of birth. Given that this category covers the largest span of time, and includes all of the other stillbirth and mortality categories within it, the reported rates for this "catch all" category are going to be the highest on the chart: 0.13% (1 in 769) for planned VBAC and 0.05% (1 in 2,000) for elective repeat cesarean delivery.
So what happens when we break out those numbers among the other subcategories representing smaller spans of time either before, during, or after birth? Neonatal mortality, which includes only deaths from birth to 28 days of life, is also low: 0.11% (1 in 909) for planned VBAC versus 0.06% (1 in 1,667) for elective repeat cesarean delivery.
Note that the risk is not zero for either measure or mode of delivery.
When we look at stillbirth, we can see that the risk of stillbirth before labor (antepartum) is low (0.10% planned VBAC vs 0.21% for elective repeat cesarean) as is the risk of stillbirth during labor (intrapartum) (0.01 – 0.04% planned VBAC vs 0 – 0.004% planned repeat cesarean).
Another outcome to note on this chart is HIE which stands for hypoxic-ischemic encephalopathy and describes an infant that has sustained brain damage as a result of oxygen deprivation. We can see that the absolute risk is again higher with planned VBAC, 0 – 0.89%, versus 0 – 0.32% in a planned repeat cesarean section, but the absolute risks are low.
Even though these numbers are from ACOG’s 2019 VBAC guidelines, they still reference the Guise 2010 Evidence Report as their source.
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The source of the confusion about “catastrophic uterine rupture”
But let’s circle back to the 6% statistic. Where did the confusion about this number and catastrophic uterine rupture emerge?
I think it’s a combination of blurring what defines a uterine rupture versus uterine dehiscence as well as a lack of clarity on how studies define uterine rupture and the ambiguous language (“catastrophic uterine rupture”) we use to describe this heartbreaking event.
The fundamental problem with this 6% statistic is that some people have misinterpreted it to mean that only 6% of reported uterine ruptures are actual uterine ruptures.
In other words, they hear a rate of uterine rupture, like 0.7% from the Landon (2004) study, and believe that only 6% of those events are “true” uterine ruptures and the rest are uterine dehiscences.
Clearly, this leaves them with the impression that the risk of uterine rupture is truly miniscule.
How often uterine rupture and uterine dehiscence occur
However, one of the largest VBAC studies, Landon (2004), which distinguished uterine rupture from uterine dehiscence, reported the rate of each to be 0.7% or 1 in 143 planned VBACs.
Keep in mind that this reflects the outcomes of 18,000 who labored after a cesarean, 63% of which were either induced or augmented. (Yes, you can induce or augment a labor after cesarean.)
When they broke out the rate of uterine rupture for those who labored spontaneously after cesarean – without induction or augmentation – the uterine rupture risk decreased to 0.4% or 1 in 240 planned VBACs.
This is the number I often use when discussing uterine rupture because – through isolating just spontaneous labor after cesarean – it gets us as close as possible to a “baseline” risk of uterine rupture.
The safety of VBAC and the risk of uterine rupture
So what does all this mean in terms of the safety of VBAC and the risk of uterine rupture?
Looking at the totality of the evidence Guise (2010) asserts both VBAC and repeat cesarean are reasonable options which often result in healthy infants:
VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans… The occurrence of maternal and infant mortality for women with prior cesarean is not significantly elevated when compared with national rates overall of mortality in childbirth. The majority of women who have TOL [trial of labor] will have a VBAC, and they and their infants will be healthy. However, there is a minority of women who will suffer serious adverse consequences of both TOL and ERCD [elective repeat cesarean delivery].
We can also look to ACOG’s national guidelines, as well as other obstetrical guidelines around the world, which have maintained for years that VBAC is a reasonable option to which women and people pregnant after a cesarean should have access. As a result, ACOG specifically encourages VBAC access and support all Level 1 hospitals to offer labor after a cesarean.
Create clarity about uterine rupture related perinatal mortality by using clear, unambiguous language
I think the best way to avoid confusion about “catastrophic uterine rupture” is to use very clear language when talking with birthing families: uterine rupture related ____________________.
Using vague language like “catastrophic uterine rupture” – which provides us a level of comfort by avoiding stating outright that someone died – only adds to the uncertainty that many birthing families feel when discussing the rate and risk of uterine rupture and it's serious consequences.
Or even more, it contributes to erroneous beliefs among parents about the “true” incidence of uterine rupture, or the severity of its outcomes, leaving them with the false impression that the risk of uterine rupture is actually much lower than reported in the research.
This overarching lack of clarity is a barrier to true informed consent. Easy, clear, and straightforward language will mitigate this ongoing challenge of effectively communicating obstetrical risk to birthing families.
How to talk to patients about uterine rupture related perinatal mortality
Given all the information we have discussed, what statistics should we cite and how do we communicate it to parents?
ACOG still cites Guise (2010) which found that 2.8 – 6.2% uterine ruptures result in a perinatal mortality which works out to an overall risk of 1 in 2,300 to 1 in 5,100* during a planned labor after cesarean (0.02 - 0.044%.)
However, more recent data out of Europe found that 0.032% (1 in 3125) of those who labored after a cesarean experienced a uterine rupture related perinatal mortality. Expressed another way, of the labors who had a uterine rupture, 9% had a fetal/infant death.
In addition to those stats, it's important to talk about the factors that impact uterine rupture outcomes, most pointedly time, and how your facility/practice works to ensure the best possible outcomes. Also consider what you could do to improve those outcomes.
Finally, it's important to express that while you will do everything in your power to generate a good outcome if a uterine rupture occurs, no one can predict or guarantee a specific outcome. We know that there is a spectrum of uterine rupture outcomes so it's important to share that range including the worse case scenario.
The objective here isn't to downplay or exaggerate, just be clear about the reality of the situation, the data, the options, and that the ultimate decision is theirs.
During these discussions it's relevant to contrast the risk of uterine rupture in the current pregnancy during a planned VBAC against the risk of placenta accreta and previa in future pregnancies if one planned a repeat cesarean now.
It's vital for parents to understand that while uterine rupture is a real, though relatively small, risk, planning a repeat cesarean does not eliminate risk. It simply delays it until the next pregnancy as that repeat cesarean increases the likelihood they will experience other serious conditions which carry significant risk of maternal and perinatal complications including death.
Repeat cesareans also increase the incidence of medical emergencies beyond the childbearing years such as bowel obstructions which also carry a significant risk of death especially if not diagnosed rapidly.
While many parents pregnant after a cesarean are well aware of the risk of uterine rupture, few ever experience the opportunity to make an informed decision because cesarean risks like accreta, previa, and bowel obstructions are never discussed with them. They are left with the impression that only planned VBAC carries risk. That is simply not the case.
Take home message
Now you know the difference between uterine rupture, uterine dehiscence, and catastrophic uterine rupture. You also know that the 6% statistic refers to uterine rupture related perinatal mortalities. And that more recent data indicates that number may be as high as 9%.
It’s vital to understand the terminology used relative to uterine rupture in order to make sense of not only medical studies, but also to facilitate conversations between parents and clinicians.
I also think it’s very important for people to use specific words whose definitions are clear instead of phrases like “catastrophic uterine rupture” that could mean multiple things to multiple people. I have found it especially confusing to birthing families.
As tough as it may be, unambiguous terms like “uterine rupture related fetal/infant death” might be the most understandable to parents.
In this article, we highlighted the outcome of uterine rupture related perinatal mortality – the fear of many parents. At the end of the day, and in light of the increasing risks associated with multiple repeat cesarean sections, VBAC is still considered an evidence based choice and should be available to parents who wish to peruse this safe and reasonable option. The evidence and national guidelines support it.
If you want to learn more about the data on this topic, we get more granular within our continuing education trainings where we talk more about fetal monitoring during planned VBAC, the data on uterine rupture outcomes relative to time to delivery, uterine rupture outcomes in community hospitals, and more.
We also have patient education handouts on VBAC vs repeat cesarean, community (out of hospital) VBAC, and more that communicate this information in a concise manner available within our professional membership.
Diving into the math
* I received a question from a reader on how I calculated the 1 in 2300 – 1 in 5100 range for uterine rupture related perinatal mortality, so I wanted to share that math here for others that are interested.
What I did was multiply the 0.7% risk uterine rupture by Landon by 2.8% which is 0.0196%. That’s the incidence per 100: 0.0196 per 100.
To turn that into a 1 in ______ ratio, you divide 100/0.0196. That gives 5102 which I rounded to 5100, so 1 in 5100.
Do the same process with 6.2%:
6.2% * 0.7% = 0.04340%
Rate: 0.04340 per 100
Create the ratio of 1 per _____ by dividing 100/0.0434 = 2304, round down and that’s 2300
Final ratio: 1 in 2300
So using the uterine rupture rate of 0.7% and the 2.8 – 9% uterine rupture related perinatal mortality rate range, we can calculate the risk of uterine rupture related perinatal mortality in a given planned VBAC to be 1 in 1600 – 1 in 5100.
Now, we could crunch these numbers using different uterine rupture figures, but given the incidence of induction and augmentation, I thought the 0.7% was a good overall number.
Jen
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About Jen Kamel
founder of VBAC Facts®️
Jen Kamel is the CEO and Founder of VBAC Facts® Since 2007, her focus has been to provide objective, accurate information about the data available on VBAC and repeat cesarean to parents, professionals, policymakers, and the court so all decisions can be informed, ethical, and just. VBAC Facts® works to achieve this mission through their educational courses for parents, online membership for professionals, continuing education trainings, and consulting services.
As an internationally recognized consumer advocate, Jen speaks at conferences across the world, presents Grand Rounds at hospitals, advises on midwifery laws and rules that limit VBAC access, educates legislators and policy makers, and serves as an expert witness and consultant in legal proceedings.
VBAC Facts® envisions a time when every pregnant person seeking VBAC has access to unbiased information, respectful providers, and community support so they can plan the birth of their choosing in the setting they desire.
What do you think?
Leave a comment.
Nice article. It is important for parents to keep in mind that this mortality rate is based on babies born in hospital. The mortality rate for rupture at a homebirth would likely be much higher, since time is so much of the essence when a rupture occurs.
Becky, I’m not sure you can so simply draw that conclusion. Lack of unnecessary interventions, freedom of movement, lack of restrictions of food and fluids, close attendance of the hb midwife, and overall greater level of comfort of the mother very likely would decrease the incidence of complications in the first place. Furthermore, close observation of the mw to spot issues early on and call ahead while in transport to hospital can decrease risks.
“Lack of unnecessary interventions, freedom of movement, lack of restrictions of food and fluids, close attendance of the hb midwife, and overall greater level of comfort of the mother very likely would decrease the incidence of complications in the first place.”
Do you have any evidence for any of this? The one difference might be the lack of augmentation or induction at home, but homebirths may be more likely to be prolonged labors, which is also a risk factor for a uterine rupture.
In any case, *if a rupture happens,* we already know that time is of the essence to prevent a death or brain damage. Being a half or more away from the OR instead of 10 minutes absolutely will affect the mortality rate.
Katie thats not true a uterus rupture is not something that can be prevented with lack of intervention and food in take during child birth at home. I’ve had it happen and me and my son are happy and well thanks to the doctors and nurses that acted quickly. I’m sure if I was home my life would be very different. I think your statement is quite ignorant and you are unaware of what its like to endure that kind of trauma. And just so you know the time it takes for an ambulance to get you from your home to a hospital could be much to long. You or your baby could be one of those catastrophic ruptures. I’m greatful for my life and my sons life. Its all because of the doctors, nurses and surgeons in a facility capable to handle those kind of problems.
Stephanie, you said “uterus rupture is not something that can be prevented with lack of intervention”. That is mostly false (I use “mostly” instead of “absolutely” only due to the fact that ruptures cannot be fully prevented in any pregnant woman’s circumstances). Interventions such as inductions, epidurals, anesthesia and coached pushing CAN have an impact on UTERINE rupture rates. The less the body is messed with while in labor (or to put it into labor), the more likely things will turn out well. I’m sorry that you had a rupture, but the fact of the matter is just because YOU felt better to have your vbac in a hospital (I am assuming it was a vbac, but uterine ruptures do occur in vaginal deliverers without have prior c/s, so I can’t be sure) doesn’t mean the risks are higher at home or that interventions don’t cause more ruptures (possibly causing more ruptures than the lives they save even, possibly). The differences in a woman’s comfort and lack of interventions experienced at home do have an impact. And who is to say that the increased stress in a hospital setting, that causes increased adrenaline, wouldn’t contribute to a rupture? The factual statistics aren’t there for all of this yet. But there has been some proof that interventions can contribute to bad outcomes in vbacs and in TOLAC.
As much as I’m a proponent of home and natural birth, I think it’s pretty dangerous to do a first VBAC at home–should there be a uterine rupture, you could lose both mother and baby, and there really isn’t time to get to the hospital in that situation. You can still have all those things in hospital with a CNM or other provider willing to give the support necessary.
GL,
Home VBAC carries that risk. So let’s work to make hospital VBAC a reality for more women by sharing quality information with moms and care providers (https://www.vbacfacts.com/2012/04/11/best-compilation-of-vbac-research-to-date), strategies so hospitals without 24/7 anesthesia can safely offer VBAC (https://www.vbacfacts.com/2010/07/22/vbac-ban-rationale-is-irrational/), and demonstrate how these policies makes birth safer for everyone (https://www.vbacfacts.com/2012/03/27/just-kicking-the-can-of-risk-down-the-road).
Warmly,
Jen
I was with a woman who wanted to have a VBAC at home. She was 8cm when she insisted ‘something was wrong’. An ambulance was called, she was transported to hospital and everyone flew into action. Surgery determined her baby had delivered into her abdominal cavity but both mother and baby were fine. The surgery was performed about 1.25 hours after she initially felt something was wrong. The lesson for me . . . always listen to the mother!
Hmmm,always something to think about. How about we prevent unnecessary c-sections in the first place. We could help families to make decisions based on fact instead of fear. We sometimes feel like we can have all of the answers, but reality is that not all births are picture perfect,even in the best of circumstances.
Joanne,
I completely agree. We need to prevent unnecessary primary (and repeat) cesareans. One of the things that can make that happen is for women to be aware of how the risks increase in post-cesarean pregnancies regardless of the mode of delivery, and especially if a mom has multiple repeat cesareans. Unfortunately, primary and repeat cesareans are generally viewed as benign by the public.
Warmly,
Jen
I had to have a c section with my first child. There were complications, as my cervix swelled, I stopped dialating, and she went into distress. Afterwards, they realized she was stuck. The c section was needed but now I am pregnant with my second and want to do a VBAC. I met with my new doctor today, as we recently moved. I felt she was trying to sway me to have another c section. She told me I was at risk for things to go wrong during VBAC because of the complications with my first birth. I am concerned about the risks during a VBAC. I feel confused and uncertain. Any comments are appreciated.
Amber,
I’ve posted your question here.
Best,
Jen
Amber,
I shared your comment over on Facebook. Join us there to view the responses.
Best,
Jen
These statistics are only relevant to hospital birth. The neonatal mortality rate following uterine rupture is low +/- 6% IF DELIVERY IS WITHIN 16-28 MINUTES from the time of rupture. Which is nearly impossible if transporting from home, even if you live near the hospital. After this timefram has passed, neonatal mortality rates rise to 60%. Do the research. This kind of article is dangerous and irresponsible.
Cara,
Absolutely. I reference the 17 minute time frame in the article above which is one of the risks of homebirth.
Best,
Jen
Totally agree that the confusion here comes down to the use of the word ‘catastrophic’. If, by ‘catastrophic’, folks mean ‘someone dies’, this is where the waters get muddied (in the case of the Landon, 2004 stats, anyway). It is so important to mind one’s language with regards to stat discussion.
In South Australia, our government perinatal guidelines reference a VBAC rupture rate between 0.5% and 1% (stating that “most series” report this). I wondered if you could point me in the direction of the series which report a rupture closer to 1%? I am keen to know if these reports include dishiscences as well as complete ruptures.
Thank you kindly!
Hi Tessa,
Here are two sources:
Landon (2004) reported a uterine rupture rate of 1.0% among induced labors.
Mercer (2008) reported a rate of 0.87% among spontaneous labors and 1.37% among induced labors.
Hope this helps!
Jen
Hi,
This addresses VBAC after 1 caesarean. I was very lucky to deliver vaginally (a perfect birth, thank G-d!) after my first 2 caesareans. But since then I have had 2 more. What resources can you point me to that discuss my chances of a healthy natural birth after 4 caerareans?
Thanks so much.
Hi Esther,
The truth is, there isn’t much evidence on vaginal birth after multiple cesareans. Go here to learn more.
Jen, love this article and using it as a great reference! Can you explain the statistics for perinatal mortality after uterine rupture. ” research shows that 2.8-6.2% (1 in 2,380 to 1 in 5,100). Could you explain all the numbers that go into this equation. I realize it is based on the .4% risk of uterine rupture when IOL and induction is taken out. I apologize for this lack of ignorance on my part. Numbers are not my strong suit.
Hi Jennifer!
This is a great question because the math can be confusing and I’m sure others have similar questions.
What I did here was multiply the 0.7% risk uterine rupture by 2.8% which is 0.0196%. That’s the incidence per 100: 0.0196 per 100.
To turn that into a 1 in ______ ratio, you divide 0.0196/100. That gives 5102 which I rounded to 5100, so 1 in 5100.
Do the same process with 6.2%:
6.2% * 0.7% = 0.04340%
Rate: 0.04340 per 100
Create the ratio of 1 per _____ by dividing 0.0434/100 = 2304 (opps, I see a typo in the article as I have it written there as 2380, so I will fix that)
Final ratio: 1 in 2304
So using the uterine rupture rate of 0.7% and the 2.8 – 6.2% uterine rupture related perinatal mortality rate range, we can calculate the risk of uterine rupture related perinatal mortality in a given planned VBAC to be 1 in 2300 – 1 in 5100.
Now, we could crunch these numbers using different uterine rupture figures, but given the incidence of induction and augmentation, I thought the 0.7% was a good overall number.
Did that help?
Hi Jen,
Thank you for information. I just had a visit with my OB and he mentioned the 0.5-1% chance of rupture with VBAC. He also used the terms “catastrophic” mentioning the risks of fetal brain damage or death should this happen but did not provide context for how often this was the case I.e the “6%” often quoted. I wonder if you have any insight into how frequently brain damage would occur as opposed to fetal death – are the two primarily lumped together in the literature ? I saw the statistic about HIE VBAC-0.89% vs 0.32% repeat C-section… but wasn’t sure how that math factored in. Can you also clarify which link talks about intervention times necessary to prevent the above occurrences ? I am planning a hospital birth, but do not live in a major city and was told by my OB, therefore the wait could be about an hour if a ruptured occurred when the OR was full or in the night if anesthesia needed to be called in. I initially felt much better after reading the statistics in this article but now am not sure if the apply to me or if I will sadly sway towards a repeat C Section given my hospital location 🙁
Thank you
Thanks for this question. I’m sure other readers have wondered the same.
HEI is caused by oxygen deprivation and HEI can result in long term brain damage. One of the challenges with the available studies is that they do not follow up with HEI infants over longer periods of time to see their HEI resulted in long term problems – such as brain damage – or not. While there is no magic time that prevents all adverse outcomes due to uterine rupture, the risk of brain damage or death does increase as time elapses and waiting 60 minutes for a cesarean would almost certainly result in a very bad outcome.
If you want to review the available research and get clarity on the facts so you can make an informed decision, we have a 60 minute training on fetal monitoring during VBACs which includes the research on response times. This training is available within professional membership which you can join now for only $49. Click here to learn more. If you’d like to talk through your question more, you are welcome to schedule a consultation with me.